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MRSA Screening Laws: Implementation and Beyond!                  
 

By Cheri Graham-Clark RN, MSN, CPHQ, CPHRM and
Janet Hanley, RN, BSN, MBA, NEA, BC
Quality & Patient Safety Committee
 

Cheri Graham-Clark 

Janet Hanley

Background: Why is it Important?

  • 59% of all skin infections in U.S. emergency departments are caused by MRSA. 1
  • In 2006-2007, MRSA accounted for >50% of S. Aureus isolates from patients in ICUs. 5
  • In 2005, there were an estimated 94,000 invasive MRSA infections in the United States. These were associated with nearly 18,000 deaths. Of these invasive  infections, 86% were associated with healthcare delivery, and two-thirds of the healthcare-associated infections had their onset  outside the hospital setting.1                         
  • Infection surveillance data analysis from 149 NICUs in the National Nosocomial Infections Surveillance (NNIS) systemfrom 1995 through 2004 identified  that the rate of late-onset MRSA infections increased significantly for all birth weight groups. 3

In December 2005, the Healthcare Associated Infections Advisory Working Group provided a report to California Department of Health Services (DHS) providing evidence-based recommendations aimed at reducing the morbidity and mortality from the Healthcare Associated Infections (HAI) in California. 4

What is Required in California?

California Senate Bills 739 (2006), 158 (2008), and 1058 (2008) have affected the practice of infection prevention and control.

Senate Bill 739

  • Created the Healthcare Associated Infection Advisory Committee (HAI AC), a multidisciplinary committee that includes healthcare experts and consumers.
  • The HAI AC provides recommendations to the California Department of Public Health (CDPH) related to methods of reporting cases of hospital-acquired infections  occurring in general acute care hospitals, and makes recommendations on the use of national guidelines and the public reporting of process measures for preventing the spread of HAIs.
  • The HAI AC reviews and evaluates federal and state legislation, regulations and accreditation standards and communicates to the department about how hospital infection prevention and control programs will be impacted.

The Committee was appointed by the department on July 1, 2007. The committee’s duties are written into the CA Health and Safety Code Section 1288.5 to 1288.8. Due to budgetary constraints, the last meeting of HAI AC was January 12, 2009.

Senate Bill 1058: Medical Facility Infection Control and Prevention Act or Nile’s Law  7

  • Affects general acute care hospitals.
  • Violation of the provisions is a crime.

Effective January 1, 2009
Establish an active surveillance program to test for MRSA within 24 hours of admission for the following patient groups:

  • Patients who are scheduled for inpatient surgery and have a documented medical condition making them susceptible to infection, based either upon federal Centers for Disease Control and Prevention findings or the recommendations of the committee or its successor.
  • Patients who are admitted and were previously discharged from an acute care hospital within the past 30 days.
  • All admissions to an intensive care or burn unit.
  • Patients who receive inpatient dialysis treatment.
  • Patients transferred from a skilled nursing facility.

In addition:

  • If a patient tests positive for MRSA, the attending physician shall inform the patient or the patient’s representative immediately, or as soon as is practically possible.
  • A patient who tests positive for MRSA infection shall, prior to discharge, receive oral and written instructions regarding aftercare and precautions to prevent the spread of the infection to others.
  • Effective January 1, 2011, a patient tested who shows evidence of increased risk of invasive MRSA shall again be tested for MRSA immediately prior to discharge from the facility. This does not apply to a patient who has tested positive for MRSA infection or colonization upon entering the facility.
  • No later than January 1, 2011, post on the department’s (CDPH) website information regarding the incidence rate of healthcare associated MRSA bloodstream infection.
  • Beginning January 1, 2009, submit quarterly data to the State Department of Public Health on the following
       -Healthcare-Associated - MRSA bloodstream infections
       -Surgical site infections from MRSA and all other organisms (whether Multiple Drug Resistant Organisms (MDRO) or not).

Senate Bill 158

  • Affects general acute care hospitals, acute psychiatric hospitals and special hospitals.
  • Violation of the provisions is a crime.
  • January 2010, all staff and contract physicians and all other licensed independent contractors, including, but not limited to, nurse practitioners and physician assistants, shall be trained in methods to prevent transmission of HAIs, including MRSA, C. difficile infection and other HAIs.

For more information about HAI requirements, us the links below to access All Facility Letters (AFL) related to Infection Control and Prevention:

December 30, 2008, AFL 09-01, Patient Safety Plans and Tube Connection
Restrictions (SB158)
www.cdph.ca.gov/services/boards/Documents/AFL09_01.pdf

January 21, 2009, AFL 09-7, Senate Bill 1058, Senate Bill 158 – Medical Facility Infection Control and Prevention Act
www.cdph.ca.gov/services/boards/Documents/AFL09_07.pdf

A reminder about reporting per SB 1058 - there is currently not a state penalty. AFL-9-07 addresses the reporting and also has a sample form for reporting with contact information for the CDPH HAI Program Coordinator. Flu data was due 4/30/09.

State Licensing and Certification survey staff have received training related to infection control practices and survey techniques. When the CDPH surveyors come to facilities in response to complaints, they are trained to look at hospital-wide practices and processes for infection control. Initially, infection control deficiencies rose, but have since normalized with continued focus on training and implementation of consistent surveying techniques. 6

What is Occurring? Are there Best Practices?

The two approaches reportedly being applied in California are: 1) screen everyone who is admitted to the hospital, or 2) screen according to regulations and high risk groups. 6

The Society for Healthcare Epidemiology of America (SHEA) and the Association of Professionals in Infection Control and Epidemiology (APIC) developed a joint position statement on state mandated active surveillance in 2007. The position statement considers the impacts, barriers and consequences of mandated surveillance. 8 In general, the position statement provides evidence to support active surveillance on high risk populations but concurs that there is no evidence indicating increased benefits from mandatory screening of all hospitalized patients. Below are unresolved issues from the position statement to consider:
 
   1 - Infection control and prevention programs and priorities
                 Loss of autonomy in risk assessment and resource allocation
                 Insufficient flexibility to respond to changes in local epidemiology or new scientific evidence
                 Insufficient infrastructure and resources
   2 - Data management
                 Lack of adequate standardization
                 Lack of adequate validation
                 Shortcomings in proposed enforcement and compliance plans
   3 - Safety
                 Potential concerns for safety and satisfaction of patients in isolation
   4 -
Logistics
                 Need for cohorting of patients in institutions without sufficient single-patient rooms
                 Barrier to discharge for colonized or infected patients (see below for pending SB687 legislation)
                 Insufficient laboratory infrastructure and resources
                 Added risk for laboratory delays and errors because of marked increase in volume.
8

An evaluation of technology is critical in order to determine if there are improvements in laboratory testing that can help meet the state mandate for screening and ultimately the demands of CMS and third-party payers refusing to pay for HAIs. Other considerations include: financial resources needed for technology upgrades? Will CMS and third-party payers pay for active surveillance?

Hospitals and other healthcare facilities need to look at their infection control programs and determine if and when rapid testing (i.e., tests that give results in 2 hours rather than the 48 hours required for cultures) may fit. Hospitals should refer to published evidence reports on these topics and consider how to measure outcomes regarding impact on HAI rates with the understanding that infection control programs and protocols may need adjustments based on evidence collected. 9

Sharp Grossmont Hospital is currently involved in a research study that targets active surveillance screening for MRSA in the adult medical and surgical intensive care units in an acute care magnet designated community hospital. The purpose of the study is to evaluate the effects of an active screening program on the transmission rate of healthcare associated MRSA. Patients are screened on admission and discharge of the unit. The study will continue for the next several months.

What’s New and What’s Next?

New California legislation related to Infection Control and Prevention

  • AB 542 Hospital acquired conditions
  • SB 212 Pupil health: communicable diseases - minimize the spread of MRSA and meningococcal disease
  • SB 769 Federal funding: supplemental appropriations - pandemic flu.
  • SB 687 Long-term health care facilities: health-care-associated infection

Most significant to watch are SB 687 and AB 542. SB 687 is related to patient acceptance at SNFs after hospitalization, and states “consistent with state laws in effect on January 1, 2010, cannot refuse to take a patient due to diagnosis of a HAI or testing positive for the presence of an organism."

AB 542: has been changed from an adverse medical events to hospital acquired conditions legislation. It sets the standard that:

  • A facility’s medical director and CNO submit an annual adverse events and hospital acquired conditions report to the board
  • No reimbursement for hospital acquired conditions
  • By 9/2010 Dept of Managed Care will adopt payment policies and practices regarding nonpayment for substantial hospital acquired conditions that is consistent with CMS definitions
  • New revisions of the bill establish guidelines and procedures for health facilities to report the occurrence of hospital acquired conditions to the State Department of Public Health, the Office of Statewide Health Planning and Development, or any other appropriate agency or department. 10

CMS developed new infection control guidelines in the state operations manual in 2008 for Acute Hospitals. (See pages 241-245) www.cms.hhs.gov/EOG/downloads/EO%200307.pdf

Effective 5/18/09, CMS put out new conditions of coverage and guidelines for ambulatory surgery centers. www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/itemdetail.asp?filterType=none&filterByDID=99&sortByDID=4&sortOrder=ascending&itemID=CMS1223256&intNumPerPage=2000

CMS will be publishing new infection control guidelines for Skilled Nursing Facilities this year. APIC has already provided comment on these guidelines. 6

In June 2009, Department of Health and Human Services published the Final Action Plan to Prevent Healthcare-Associated Infections, a collaborative effort among CDC, AHRQ, NIH, CMS and others. 1 One of the stated goals is a 50% reduction in incidence rate of all healthcare-associated invasive MRSA infections. Stakeholder meetings are being were held in July and August (see HHS link for more information).  

Some of the research gaps identified in the HHS Plan include: 

  • Laboratory science research on antigens, host determinants and virulence
  • Epidemiology research to understand colonization and transmission; patient characteristics related to risk of carriage; impact of community MRSA on healthcare associate infection; the preventability of colonization
  • Prevention practices research to measure transmission; determine if eradication of colonization impacts transmission; determine the optimal role of surveillance in detecting asymptomatic carriage
  • Care and treatment research to evaluate optimum antibiotic use and control 1
How to meet the next steps of MRSA screening on discharge?

SB 1058 has a component effective January, 2011, whereby a tested patient, showing evidence of increased risk of invasive MRSA, shall again be tested immediately prior to discharge from the facility.

The Quality & Patient Safety Committee invites you to the Member Forum on the ACNL website to discuss this important topic, share best practices, describe how you are overcoming barriers, and how your facility plans to meet this next step. Please join the discussion. We value your opinion and insights. Use this link to access the ACNL Member Forum:  www.acnl.org/forum.cfm                       

Useful Links

HHS initiative on Preventing Healthcare-Associated Infections
www.hhs.gov/ophs/initiatives/hai/index.html

A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care hospital
www.journals.uchicago.edu/toc/iche/2008/29/s1

CDPH MRSA Resource Page
www.cdph.ca.gov/HealthInfo/discond/Pages/MRSA.aspx

Healthcare-Associated Infection Advisory Committee (HAI AC)
www.cdph.ca.gov/services/boards/Pages/HAI_AC.aspx

California Legislation Site
www.leginfo.ca.gov/
SB 687   www.leginfo.ca.gov/cgi-bin/postquery?bill_number=sb_687&sess=CUR&house=B&author=alquist
AB 542   www.leginfo.ca.gov/cgi-bin/postquery?bill_number=ab_542&sess=CUR&house=B&author=feuer

Helpful Contacts

CDPH HAI Program Coordinator
Sue Chen - Sue.Chen@cdph.ca.gov or phone:  510.620.3434

HHS Action Plan to Prevent Healthcare-Associated Infections
Ms. Rani Jeeva - Rani.Jeeva@hhs.gov,  phone:  202.205.5245,  fax:  202.690.7425


References

1. Department of Health and Human Services. HHS Action Plan to Prevent Healthcare-Associated Infections. June 22, 2009.
    www.hhs.gov/ophs/initiatives/hai/draft-hai-plan-01062009.pdf

2. Center for Disease Control. Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006.
    www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf

3. Lessa, Fernanda C.; Edwards, Jonathan R.; Fridkin, Scott K.; Tenover, Fred C.; Horan, Teresa C.; Gorwitz, Rachel J. Trends in Incidence of Late-Onset 
    Methicillin-Resistant Staphylococcus aureus Infection in Neonatal Intensive Care Units: Data From the National Nosocomial Infections Surveillance
    System, 1995-2004. The Pediatric Infectious Disease Journal. 28(7):577-581, July 2009. Abstract access: www.journals.lww.com/pidj/pages/currenttoc.aspx

4. Healthcare-Associated Infections Advisory Working Group.
    Final Report to the California Department of Health Services
    www.cdph.ca.gov/pubsforms/Guidelines/Documents/HAIAWGReporttoDHS.pdf

5. Alicia I. Hidron, MD; Jonathan R. Edwards, MS; Jean Patel, PhD; Teresa C. Horan, MPH; Dawn M. Sievert, PhD; Daniel A. Pollock, MD; Scott K. Fridkin, MD; for 
    the National Healthcare Safety Network Team and Participating National Healthcare Safety Network Facilities. Antimicrobial-Resistant Pathogens Associated
    With Healthcare-Associated Infections: Annual Summary of Data Reported to the National Healthcare Safety Network at the Centers for Disease Control and
    Prevention, 2006–2007. Infection Control and Hospital Epidemiology, vol. 29, no.11, November 2008. www.cdc.gov/nhsn/PDFs/AR_report2008.pdf

6. Jennifer Hoke, MSN, RN, CPDH Infection Control Practitioner, Section Chief, Certification & Regulations, CDPH, Licensing & Certification; Telephone Interview,
     6/4/09.

7. James Marx, RN, MS, CIC. APIC Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital Settings - California
    Supplement. February 11, 2009.  www.premierinc.com/safety/safety-share/04-09-downloads/8-MRSA-CA.pdf

8. Joint SHEA and APIC Task Force: Stephen G. Weber, MD, MS; Susan S. Huang, MD, MPH; Shannon Oriola, RN, CIC, COHN; W. Charles Huskins, MD, MSc;
    Gary A. Noskin, MD; Kathleen Harriman, PhD, MPH, RN; Russell N. Olmsted, MPH, CIC; Marc Bonten, MD, PhD; Tammy Lundstrom, MD, JD; Michael W. Climo,
    MD Mary-Claire Roghmann, MD, MS; Cathryn L. Murphy, MPH, PhD, CIC; Tobi B. Karchmer, MD, MS. Legislative Mandates for Use of Active Surveillance Cultures
    to Screen for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci: Position Statement . 2007.
    www.apic.org/Content/NavigationMenu/GovernmentAdvocacy/IssuesInitiatives/MandatoryReporting/PositionPapers/2007_SHEA_APIC_MRSA_Active_surv.pdf

9. ECRI Institute. Top 10 Hospital Technology Issues: C-Suite Watch List for 2009 and Beyond. Revised 5/21/09.
    www.ecri.org/Press/Pages/Top _10_Hospital_Technologies.aspx

10. California Legislation Site. Accessed 6/5/09 and 7/2/09. www.leginfo.ca.gov/